Aphasiology

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Luria’s classification of aphasias and its theoretical

basis

Tatiana Akhutina

To cite this article: Tatiana Akhutina (2016) Luria’s classification of aphasias and its theoretical
basis, Aphasiology, 30:8, 878-897, DOI: 10.1080/02687038.2015.1070950

To link to this article: http://dx.doi.org/10.1080/02687038.2015.1070950

Published online: 06 Aug 2015.

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Aphasiology, 2016
Vol. 30, No. 8, 878–897, http://dx.doi.org/10.1080/02687038.2015.1070950

Luria’s classification of aphasias and its theoretical basis

Tatiana Akhutina *

Department of Psychology, Lomonosov Moscow State University, Moscow, Russia

(Received 4 July 2015; accepted 4 July 2015)

Background: Every qualified neuropsychologist knows about Luria’s contribution to

neuropsychology and aphasiology in general, but many of them believe his ideas to be
out of date.
Aims: The purpose of this article is to investigate Alexander Luria’s methodology of
classification of aphasias and to describe the forms of aphasias that he distinguished.
Main contribution: The article shows that the classification of aphasias was based on
a profound theoretical research performed by Luria together with the founder of
cultural-historical psychology, Lev Vygotsky. Their theoretical views including
systemic, dynamic, evolutionary, and socio-cultural approaches to the analysis of
functioning and disintegration of higher mental functions are congenial to the con-
temporary cognitive neuroscience. The descriptions of Luria’s classic forms of
aphasia are updated using more recent data from Russian aphasiologists. The article
provides the comparison of Russian and Western classifications of aphasias.
Conclusions: Understanding the main ideas of the Vygotskian–Lurian neuropsychology,
and particularly of Luria’s classification of aphasias, may be useful for the contemporary
cognitive neuroscience and for the rehabilitation of patients with aphasia.
Keywords: aphasia; classification; A. Luria; L. Vygotsky; Vygotskian–Lurian
neuropsychology; syndrome analysis

For Alexander Luria, the classification of aphasias was not only an empirical task but also
the result of deep theoretical work based on the theories of the cultural-historical school of
psychology developed by Lev Vygotsky and his disciples (see Akhutina & Shereshevsky,
2014). First of all, Luria proceeded from the understanding of higher mental functions
(HMFs) elaborated by Lev Vygotsky: “. . .the higher human mental functions are complex
self-regulated processes, social in origin, mediated through structure and conscious and
voluntary in their mode of function” (Luria, 1980, p. 30—the translation was altered
according to the Russian edition). Vygotsky and Luria developed the main principles of
the formation, functioning, and disintegration of HMF. These are the principles of social
genesis, systemic structure, and dynamic organisation and localisation of HMF.
The principle of social genesis of HMF was formulated by Vygotsky in this statement:
“. . .every function in [a] child’s cultural development appears on the stage twice, in two
planes, first—social, then—psychological; first, between people as an inter-mental
category, then within a child as an intra-mental category” (Vygotsky, 1997b, p. 106). The
transition from joint social functioning to an individual’s mental function, in other words the
process of internalisation, is the transition from external to internal, at the same time: “Every
higher mental function was external because it was social before it became an internal,
strictly mental function”. On neuropsychological aspects of the concept of internalisation,
see Vygotsky (1997b, p. 105); and also Achutina (2004) and Toomela (2014).

*Email: akhutina@mail.ru

© 2015 Taylor & Francis

 Aphasiology 879

Vygotsky describes the stages of internalisation using the example of voluntary

actions:

First, an inter-psychological stage—I order, you execute. Then an extra-psychological stage

—I begin to speak to myself. Then an intra-psychological stage—two points of the brain
excited from outside [that are externally stimulated—T.A.] have a tendency to work in a
unified system and turn into an intracortical point. (1997a, p. 106)

The contemporary studies support this view and help detail the process. At the
inter-mental stage, the fulfilment of a command (like “Where’s daddy? Look at
daddy!”) is scaffolded by the gaze direction of the adult from the baby to the daddy
(for studies of gaze following and shared attention see, e.g., Brooks & Meltzoff, 2005;
Tomasello, 2008). At the extra-mental stage, the child mediates the desired action with
the help of private speech (Diaz & Berk, 2014). Finally, the child performs the intra-
mental regulation of behaviour, self-mediating his or her behaviour with the assistance
of inner speech (see, e.g., Emerson & Miyake, 2003). The stages of internalisation
identified by Vygotsky are very similar to the stages of voluntary action development
described by P. Ya. Galperin (1969). These stages form the main route of interventions
in rehabilitation or remediation work.
As to the principle of the systemic structure of HMFs, Luria wrote in Higher Cortical
Functions in Man:

We are indebted to Vygotsky for his detailed substantiation of the thesis that higher mental
functions may exist only as a result of interaction between highly differentiated brain
structures, and that each of these structures makes its own specific contribution to the
dynamic whole and plays its own role in the functional system. (Luria, 1980, p. 34—the
translation was altered according to the Russian edition)

Based on the systemic character of HMFs, Vygotsky identified the primary

impaired component of functional system, its secondary systemic consequences, and
tertiary compensatory reorganisations as the parts of the brain lesion syndrome
(Vygotsky, 1993, pp. 255–256).
Finally, the principle of dynamic organisation and localisation of the HMFs suggests a
variability of each function’s structure and localisation (Vygotsky, 1995). The dynamic
localisation occurs because of (1) structure modification of functions through ontogenesis;
(2) modification of the functional structure depending on the level of automatisation; and
(3) the possibility of using different means to achieve the same result; for example,
different strategies of information processing, such as holistic vs. analytic.
The two latter principles comprise the theory of “functional systems” (FSs) in its
psychological adaptation. This term was introduced and developed by the well-known
Russian physiologist, Petr Anokhin (Anokhin, 1935, 1980). Very similar ideas were
developed by another well-known physiologist, Nikolay Bernstein (Bernstein, 1935,
1967). Luria underlined the following characteristics of FSs: The functional system
constitutes a single, complex and labile unit of activity. One of the basic features of
every FS is the presence of a constant task performed by variable mechanisms bringing
the process to a constant result. The components of any FS may change in different stages
of its development or as a result of pathological conditions (Luria, 1965, 1970, p. 87,
1973, p. 28; a modern point of view on the concept of FS, see Alexandrov, 2008, 2009).
Stemming from these principles, a new diagnostic approach was developed: a
syndrome analysis of brain lesion symptoms (Luria, 1970, p. 251, 1980, pp. 82–86;
880 T. Akhutina

see also; Akhutina et al., in press). According to this approach, one has to identify the
primary impaired component (the primary defect), the secondary systemic conse-
quences of the primary defect, and tertiary compensatory reorganisations as the parts
of the brain lesion syndrome in adult patients or of abnormal development in children
(Akhutina & Pylaeva, 2012).
Moreover, for the understanding of the idea of Luria’s syndrome analysis of disorders
of HMF, one needs to take into account his evolutionarily oriented approach to neurop-
sychology. Vygotsky and Luria along with the aforementioned physiologist Nikolay
Bernstein believed that the history of behavioural organisation in phylogenesis is reflected
in the structure of the brain: “The brain preserves in itself in a spatial form the docu-
mented temporal sequence of development of behavior” (Vygotsky, 1998, p. 123) and “the
development of [the] brain proceeds according to laws of stratification and superstructure
of new storeys over the old one” (Vygotsky, 1997b, p. 102). From this point of view, new
structures are built on top of the old ones while preserving the principal relatedness, the
same working style, or the “common factor”, in Luria’s terms (Luria, 1970, pp. 101–103,
see also p. 370). This is why, when describing aphasia syndromes, Luria not only wrote
about speech/language itself but also considered related non-verbal deficiencies. This
approach is very similar to the modern understanding, according to which “language (as
well as other abstract or higher order skills) emerges from, and is intimately linked to, the
more evolutionarily entrenched sensorimotor substrates that allow us to comprehend
(auditory/visual) and produce (motor) it” (Dick et al., 2005, p. 238).
Because of their common morphogenesis and close functional connections, certain brain
structures are more closely associated with each other, and the disturbance in the functioning
of one with high probability will be accompanied by the dysfunction of the other. This is the
foundation of the “factor analysis” or “syndrome analysis”. Luria started developing this
analysis in “Traumatic Aphasia”, when he searched for the common factors behind the
disturbances of marginal and primary speech areas (Luria, 1947/1970). In this book, Luria
writes: “When a lesion of a primary speech area is observed, we may expect to see gross and
complex aphasic symptoms, whereas with lesions of the marginal areas, more subtle and
limited impairment of speech processes is to be expected.” He goes on to say that gross and
complex aphasic symptoms are too difficult to analyse, and therefore “we attempt to under-
stand complex aphasic syndromes by studying the partial disturbances which arise with
lesions limited to the marginal areas” (1970, p. 102). Luria puts forward the following very
important notion: “For us the study of marginal zone lesions will not be simply an investiga-
tion of the symptoms arising from ‘lesions to neighboring areas’ but rather a methodological
step towards unraveling more complex forms of aphasia into their constituent parts” (Luria,
1970, pp. 102–103, italicised by Luria).
Following this path, Luria first considers speech and movement disorders in premotor
area lesions that do not affect the classical Broca’s area. He writes that damage to the
premotor areas, especially to the left premotor area, leads to the loss of the automatic
character of motor habits, when a single generalised impulse is insufficient to generate a
series of movements. In very severe cases, smooth movements give way to chains of
individual acts, each of which is evoked by a special effort (Luria, 1970, p. 171).
Describing speech impairments following lesions of the bordering on Broca’s area,
Luria reveals “a loss of the smoothness of speech which is simply one aspect of the
change in the smoothness of movements” (Luria, 1970, p. 176).
Moving on to the disturbances of inferior parts of the premotor area (see Figure 1 left),
Luria also notes here the same disturbance in complex consecutive syntheses, including an
inability to construct complex systems of articulations and a difficulty in inhibiting
 Aphasiology 881

Figure 1. Schematic diagrams of lesions in cases of efferent motor aphasia (left) and dynamic
aphasia (right). From Luria (1947/1970) “Traumatic Aphasia”. © 1947 A.R. Luria, Editing House of
Academy of Medical Sciences. Reproduced from Luria, 1947 with permission of E.G.
Radkovskaya. Permission to reuse must be obtained from the rightsholder.

preceding articulations for a smooth transfer from one articulation in a series to the next.
These dynamic difficulties constitute the essence (the primary defect) of the true “Broca’s
aphasia”, or, as it is conventionally called, “efferent (kinetic) motor aphasia” (Luria, 1970,
p. 187, 1966).

Efferent motor aphasia

The primary defect in efferent motor aphasia is the breakdown of the word articulatory
programme. In severe cases, patients who are able to imitate individual movements of the
tongue and lips and repeat isolated sounds are unable to pronounce a serially organised set of
articulations that make up a word. In these patients, there is a breakdown of the normally
strongly automated smooth series of efferent commands that make up the articulatory schema
of a word. As a result, although they can manage the articulation of individual sounds, they
cannot pronounce them as part of the whole word that is composed not of “pure sounds” but
their positional forms, which depend on the preceding and following sounds in the word.
Sheila Blumstein and her colleagues revealed different kinds of articulation problems in
aphasia: the difficulties in organisation of articulation in time, i.e., dynamic changes in realisa-
tion of words and utterances, and the disability to find the place of articulation (Blumstein, 1981;
Shinn & Blumstein, 1983). Russian studies of articulatory problems in efferent motor aphasia
patients reveal the following defects:
I. Dynamic changes when pronouncing sounds: (1) prolongation of initial and final
consonants and stressed vowels to 300–400 ms at a normal rate of 72–120 ms; (2)
prolongation of transient phases of articulation, e.g., gof →gouf; (3) jerky articulation of
consonants in two attempts; (4) desynchronised, strained pronunciation, e.g., the transfor-
mation of voiced consonants to unvoiced ones as in b → p, substitutions as in s → t, rol“→
rol, l-l”; and (5) simplification of affricates, e.g., c → t + s, c → t/s.
II. Simplifying the structure of the syllable (conversion to open syllables) and the
syllabic structure of a word: (1) closed → open syllables: on → onǝ, tut → tu . . . 160 ms
. . . tǝ (the numbers refer to the duration of the pause in milliseconds); (2) insertion of a
vowel between consonants: vosk → vosǝ . . . 140 ms . . . kǝ; (3) omission of a consonant in
consonant clusters; and (4) syllable-by-syllable uttering of a word.
III. Perseverations of syllables and words (Vinarskaya & Lepskaya, 1968).
The disturbance in complex successive syntheses leads not only to problems in motor
programming but also to the breakdown of another level of language processing: the
882 T. Akhutina

disruption of syntactic schemata of sentences. This defect can be seen in the syndrome of
efferent motor aphasia, or it can appear relatively independently when motor disorders are
rather light (we call such form of aphasia “anterior agrammatism”, or syntactic aphasia, or
dynamic aphasia 2). In some cases, the impairment of the grammatical structure of phrases
can be very blatant and takes the form of “telegraphic speech”. One of Luria’s patients
told the story of his disorder in the following words: “Here front . . . and then . . . attack . . .
then . . . explosion . . . and then . . . nothing . . . then . . . operation . . . splinter . . . speech,
speech . . . speech” (Luria, 1980, p. 235). This very severe form of “telegraphic speech” is
characterised by a pragmatic organisation of utterances (see Akhutina, 1989/2012, 1991/
2003b). The operational ground for this kind of syntax is the recursive repetition of a
predicative act that reflects a shift of attentional focus. The presupposed subject is a field
of attention, and the verbal predicate designates a focus of attention. We find this kind of
syntax in one-word utterances of children, and Elizabeth Bates sees its origin in the
orientation reaction (Bates, 1976). In patients with severe form of agrammatism, one can
observe one-word utterances (see earlier) and chained multi-word utterances (“radio—
weather—rain”). In the course of recovery, this form changes to lighter forms of anterior
agrammatism. For the less severe second form of anterior agrammatism, noun-verb (NV)
and NNV or NVN constructions are typical, e.g., Kot’a lezat’ <(the) cat to lie>; Koshka
kuritsa nesla <(the) cat hen carried>; Babushka nalivaet kruzhku <(the) granny pours out
(the) mug>. Only one syntactic rule is kept regularly: the name of an agent is in the first
place (it is a rule of semantic syntax), with all other rules violated very often. The third,
less severe form of anterior agrammatism in Russian is characterised by keeping the
simplest rules of Russian surface grammar: opposition of singular and plural forms of
nouns, opposition of nominative case of nouns (for agent/subject) and accusative case (for
object). The differences in syntactic structures used by patients with different levels of
anterior agrammatism are shown in Table 1.
Syntactic difficulties in speech production are accompanied by parallel difficulties in
speech comprehension. In patients with middle forms of agrammatism, we can see the
use of the rule “The first noun is the agent” (see Table 2, and, in more detail, Akhutina,
1989/2012, 2003b).
Luria’s account of speech disorders arising from lesions of the anterior part of the left
hemisphere also includes one other form of disturbance in spontaneous speech. It can
manifest itself in the last stages of recovery from efferent motor aphasia or it can be
observed as an independent form of speech disorder arising from a lesion of the left
hemisphere situated anteriorly to Broca’s area. Luria called it “dynamic aphasia”.

Dynamic aphasia
Lesions located near the premotor area produce the same types of disturbance of sequen-
tial ability, but the motor aspect of speech is not impaired (see Figure 1 right). The effect
of disturbance of the dynamic schemata is shifted to an earlier stage in speech production,
i.e., to a stage which precedes the speech act. Such a patient is deprived of those inner
speech schemata which determine all the later stages in the formulation of statements
(Luria, 1970, p. 208).
The patients with dynamic aphasia complain of a kind of “emptiness in their heads”
when they have to initiate active narration: “Before, I had a clear idea that I needed to say
such and such, and now I want to start, but there is nothing there in front of me, just
emptiness” (Luria, 1970, p. 208).
 Aphasiology 883

Table 1. Syntactic structures in patients with different levels of agrammatism (Akhutina, 1989/
2012).

Level of agrammatism in patients

Syntactic structure Severea Middle Light

N 51 20.5 10
NN, NNN 14 7 1
NNV (SOV) 2 4 3
NV, NAt 12 31 29
NVN (SVO) 3 29 43
Others 14 9 14
Notes: an = 8 for each group. Please find the explanations in the text. N, noun; V, verb; At, attribute; S, subject;
O, object. The typical for each level of agrammatism types of syntactic structures are highlighted in bold.

Table 2. Understanding of sentences: percentage of errors (error dispersion) (Akhutina, 1989/

2012).

Level of agrammatism

Middle Light

Active direct 8 (0–21) 3 (0–7)

Active indirect (with reversed word order) 50 (21–64) 11 (0–21)
Passive direct 68 (50–86) 19 (0–36)
Passive indirect 21 (0–36) 37 (14–64)

Note: Active direct—Malchik spasaet devochku <The boy is saving the girl>
Active indirect—Devochku spasaet malchik <The girl who the boy is saving>
Passive direct—Devochka spasena malchikom <The girl is saved by the boy>
Passive indirect—Malchikom spasena devochka < By the boy the girl is saved >

Luria hypothesised that patients with this form of aphasia were suffering from an impair-
ment of the inner schema of an utterance, as a result of which general thought could not get
embodied in an inner speech schema and thus could not serve as the basis for constructing a
narrative (Luria, 1970, p. 208). In Luria’s opinion, this impairment is engendered by the
breakdown of inner speech, which he, after Vygotsky (1987), considers a derivative of external
speech, differing from it in structure and functions. According to this point of view, inner speech
is directly tied to the abbreviation of a narrative into a general schema and the expansion of this
schema into a full utterance (see more about Vygotsky’s and Luria’s notion of inner speech and
its role in the construction of an utterance in Akhutina, 1975/2002, 2003a).
Similar ideas about the presence of the scheme of a narrative were expressed by a
well-known philosopher and literature theorist, Mikhail Bakhtin:

When we construct our speech, we always start with an image of the whole utterance, both in
the form of a certain genre schema, and in the form on an individual speech intention. We do
not string words together, we do not move from word to word, but instead we seem to fill in
the whole with the requisite words. (Bakhtin, 1979, p. 266)

It is very important to understand after Luria and Bakhtin that in the process of thought
deployment, speakers use some scheme of a future narrative (one of the prototype story
884 T. Akhutina

schemata) and insert inner words into a scheme. Without a story scheme, the working memory
will be overloaded. My studies of dynamic aphasia demonstrated that in dynamic aphasia the
story (genre) schemata are being disintegrated, and as a result the patient is unable to produce
and maintain the programme (plan) of an utterance (Akhutina, 1989/2012, 2007, p. 45).
Other researchers also confirm the presence of difficulties of verbal planning in the syndrome
of dynamic aphasia (Bormann, Wallesch, & Blanken, 2008; De Lacy Costello & Warrington,
1989; Robinson, Blair, & Cipolotti, 1998; Robinson, Shallice, & Cipolotti, 2006).
The extent to which utterance planning is disrupted may vary: in severe cases, a
patient cannot and does not attempt to initiate speech; in milder forms, the impairment
may be almost undetectable to an outside observer, and only manifest itself when there is
a need to plan a relatively extensive narrative. In the works of Luria and his followers
(Akhutina, 1975/2002; Luria, 1970; Luria & Tsvetkova, 1968), the increasing difficulty to
formulate an utterance in patients with dynamic aphasia, depending on the complexity of
the planning, is described. Tasks are ranged from 0 (no difficulty) to 3 (maximum
difficulty): short answers in a dialogue (0), long answers in a dialogue (1–2), narration
of simple events depicted in picture sequences (1), narration of content depicted in one
story-picture (2), narration of content depicted in a picture of a landscape (3), retelling (1–
3), narration on a given topic (3) (Akhutina, 1975/2002, p. 50). Let us consider the story
created by the patient Buk on the basis of the picture “The letter from the front” (prof.
Luria and I studied this case of dynamic aphasia. I quote my protocol of this narration):

The boy is reading a letter. . .. (More details, please!) The soldier is listening to him. . .. The
girl is listening. . .. The woman is listening. . .. The girl is listening. . .. (What has happened?
Tell altogether.) The joy [is] on these faces.. . . (And what has happened?) The interesting
letter.. . . (From where, do you think?) From the front.. . . (To whom?) To woman.. . . (Now tell
all together in details) The boy is reading a letter, the soldier is listening to him, the little girl
is listening to him, the woman is listening to him, the girl is listening to him. The joy [is] on
the faces.

While all of the types of aphasia described earlier occur as a result of lesions of the
frontal portion of the brain, the remaining forms of aphasia occur after damage to the
posterior portions of the dominant hemisphere’s cortex. The frontal portions of the brain
provide the “morphological basis for programming and implementing behavioral acts
varying in complexity” (Polyakov, 1966). These operations act on the basis of successive
synthesis, described as integration of excitation in a sequential, successively organised
series (Luria, 1966; see also Sechenov, 1953). In contrast, posterior brain regions are
perceptual and gnostic and perform their functions on the basis of simultaneous synthesis,
or integration of excitation in simultaneous groups. When participating in motor acts,
posterior portions of the brain monitor the performance of actions and provide adjustment
and differentiation. In terms of Jakobson–Luria, the anterior operations provide combining
elements in syntagmatic units and the posterior operations provide selection of elements
out of paradigms (Jakobson, 1964; Luria, 1964, 1976; see also Vlasova, Pechenkova,
Akhutina, & Sinitsin, 2012; Vlasova, Akhutina, Pechenkova, Sinitsin, & Mershina, 2012).
Let us consider now those forms of aphasias that occur when the posterior portions of
the left hemisphere’s cerebral cortex are damaged.

Sensory aphasia
Sensory aphasia syndrome (Wernicke’s aphasia) occurs in the case of damage to the
posterior third of the upper-temporal gyrus of the left hemisphere (see Figure 2 left). The
 Aphasiology 885

Figure 2. Schematic diagrams of lesions in cases of sensory aphasia (left) and acoustic-mnestic
aphasia (right). From Luria (1947/1970) “Traumatic aphasia”. © 1947 A.R. Luria, Editing House of
Academy of Medical Sciences. Reproduced from Luria, 1947 with permission of E.G.
Radkovskaya. Permission to reuse must be obtained from the rightsholder.

mechanism of this type of aphasia is a deficit of phonemic hearing in the absence of

elementary hearing deficits (Luria, 1970, pp. 104–135).
Impairment of phonemic perception is seen primarily in speech perception and evokes
impaired understanding and phenomena of alienated word meaning, when patients can
repeat (imitate) the pronunciation of a word, but cannot understand its meaning. In severe
cases, patients with sensory aphasia perceive other people’s speech as inarticulate noise; in
mild cases, they have difficulty only in recognising “oppositional” phonemes: (b-p, m-
m’, etc.).
Careful assessment shows that patients with sensory aphasia cannot repeat individual
sounds. This symptom is often accompanied by a substitution of oppositional phonemes (like
b—p, d—t). The problem with repetition is more severe if the patient is asked to delay the
repetition by 10 or 15 seconds.
Repetition of words suffers too. Patients would distort the word, making literal parapha-
sias (pike—bike) or verbal paraphasias (“eyes” instead of “glasses”). The same errors are
evident in naming. It is important that verbal prompting usually does not help to find the
name; this symptom is not seen in aphasias caused by parietal lobe lesions.
Comprehension of verbal instructions strongly depends on context; it is often more a
result of guessing than of genuine speech comprehension. Writing and reading abilities are
usually severely disturbed.
Expressive speech of these patients is relatively less impaired. In more severe
cases, speech becomes unintelligible and turns into “word salad”. But even when
aphasic impairments are severe, certain frequently used words, the pronunciation of
which does not require special phonetic analysis and which have long been automated
into speech motor programmes, can be pronounced without error. An example of such
set phrases are expressions like: “you know. . .,” and “I mean. . .”. Though limited in
content, these expressions may be pronounced with normal intonation. In mild cases,
patients exhibit only word-finding difficulties and make literal and verbal paraphasias.
While lexicon in patients with sensory aphasia is severely disrupted, syntax is only
secondarily disturbed. Errors are most often seen if two synonyms have different
government; in such cases, patients may use one synonym but produce a phrase in
accordance with the other synonym’s government (e.g., “a girl shouts with him”
instead of “she quarrels with him” or “she shouts at him”).
Luria (1970) and Esther Bein (1957) note that the meaning of a word’s suffix can be
understood in sensory aphasia, whereas the meaning of the word’s root cannot. Thus,
886 T. Akhutina

when the word kolokol’chik (bell) is presented (“kolokol” is a root, “chik” is a suffix that
often conveys diminutive meaning), the patient says: “something small, but do not know
what”.
Luria stated that in patients with sensory aphasia, the semantic aspect of speech is
profoundly disturbed, and the unity of sound and meaning disintegrates. He explained it
by “general inconstancy of phonemes and phonemic sequences” (Luria, 1970, p. 125). He
writes that underlying this syndrome is a phonemic hearing disorder as a result of which
the auditory image of a word is easily lost, “and all that remains of its meaning is the
general 'semantic sphere' to which its belongs” (Luria, 1970, p. 134). However, the
statement about the connection between loss of phonemic hearing and problems in
auditory comprehension and naming was disputed by some Russian and Western authors.
So, Bloomstein and her colleagues (Blumstein, Baker, & Goodglass, 1977) have shown
that comprehension disturbances in sensory aphasia only weakly correlate with the degree
of phonemic hearing deficiency. Similar data was obtained by Elena Kok (1965a), one of
Luria’s coworkers. She found that “alienation” of word meanings is highly correlated (.73)
with phonemic hearing disturbance and with naming difficulties (.55), whereas phonemic
hearing disturbance and naming difficulties correlate at the border of statistical signifi-
cance (.43). Explaining these facts, Kok supposed that the alienation of word meanings
has a dual nature: it could be connected either with a phonemic hearing disturbance or
with a word-level defect. In the translation of “Traumatic Aphasia” (1970), unlike the
original (1947), Luria wrote that “the ‘alienation’ of word meanings may arise at different
stages in the auditory recognition of words” (Luria, 1970, p. 137) and that in temporal
lobe damage, one could observe different levels of disturbances of auditory process
integration (Luria, 1970, p.139). Considering the massiveness of the disturbances in
sensory aphasia, one could assume that in this case not only the phonemic level, but
also the word level is disturbed. Namely, it is the phonological form of words that is
impaired, the disturbance of which (without the pronounced deficits of phonemic hearing)
is typical for acoustic-mnestic aphasia.

Acoustic-mnestic aphasia
This syndrome can appear as a stage in recovery from sensory aphasia or as a separate
syndrome. As a separate syndrome, acoustic-mnestic aphasia occurs when there is a lesion
in the middle and inferior portions of the left temporal lobe (see Figure 2 right). Luria
(1970) wrote that it was characteristic of these cases that in the initial period following
injury, there was no severe disruption of phonemic hearing accompanied by the usual total
agraphia and inability to communicate verbally. The primary defect is the disturbance of
auditory memory that manifests itself in forgetting words, difficulties in remembering
long sentences, or in recalling short word sequences. The instability of the auditory
images of words (lexemes) can sometimes lead to the alienation of word meanings.
Discussing the mechanism of acoustic-mnestic aphasia, Luria noted that the
posterior-inferior portion of the left temporal lobe is the newest part of temporal
area, in evolutionary terms. It consists of the posterior portion of Brodmann’s area
21 and the adjacent portion of area 37. Luria wrote: “There is probably some basis
for the idea that area 37 plays an important role in the coordination of functions
between the auditory and visual analyzers” (Luria, 1970, p. 136). This idea has
received both theoretical and empirical support (Goldberg, 1990; Tsvetkova, 1975).
Following Luria, Natalia Kalita, the student of Lyubov Tsvetkova, showed that
 Aphasiology 887

patients with acoustic-mnestic aphasia cannot evoke a visual image associated with a
given word (Tsvetkova, 1975; Kalita, 1974; see also Luria, 1966, pp. 118–119).
Psycholinguistic analysis of naming disorders in patients with acoustic-mnestic apha-
sia showed that two aspects of word meaning—referential and significative (categorical)
—are disturbed differently in the speech of these patients. The connection between an
image and a word (referential meaning) is disturbed in acoustic-mnestic aphasia, whereas
the hierarchical concept network (significative meaning) is disturbed primarily in patients
with semantic aphasia (Akhutina, 2003c, 2014; Akhutina & Glozman, 1995).

Semantic aphasia
Semantic aphasia occurs due to a lesion of the juncture of parietal-temporal-occipital areas
of the left cerebral hemisphere (see Figure 3, left). Semantic aphasia is usually seen within
a syndrome that also includes disorders of space orientation, constructive apraxia, and
acalculia. Speech impairment in semantic aphasia manifests itself in difficulties in finding
words and understanding logical-grammatical constructions.
Luria has hypothesised that the mechanism underlying the semantic form of aphasia
involves simultaneous synthesis defect. As Luria wrote, “Both the naming difficulty and
the impairment of the comprehension of complex grammatical constructions arise from
a profound disruption of the semantic epistructure of words. . .” (Luria, 1970, p. 228,
italicised by Luria). The patient understands details of what is said, but cannot combine
them into a single integrated picture. Thus, for example, a patient understands the
meanings of the words “father” and “brother,” but the meaning of “father’s brother”
is beyond him. At the same time, disruption of simultaneous synthesis leads to the
impairment of the significative (categorical) meaning of the word. According to Luria,
“The primary image represented by a word, i.e., its specific “relatedness to an object”
(referential meaning—T.A.) remains intact. But the system of relationships centered
about the word is profoundly impaired” (Luria, 1970, p. 228). Speaking about this,
Luria refers to Vygotsky who pointed to different origins of these different aspects of
meaning: “relatedness to an object” (Vygotsky’s term) is mastered as soon as a child
pronounces his or her first words; categorical meaning of a word appears when mean-
ings of words comprise a system (conceptual framework), it is a part of this system and
may be identified in terms of its place in the system (Vygotsky, 1987, Chapter 7).

Figure 3. Schematic diagrams of lesions in cases of semantic aphasia (left) and afferent motor
aphasia (right). From Luria ((1947/1970)) “Traumatic aphasia”. © 1947 A.R. Luria, Editing House
of Academy of Medical Sciences. Reproduced from Luria, 1947 with permission of E.G.
Radkovskaya. Permission to reuse must be obtained from the rightsholder.
888 T. Akhutina

The psycholinguists in their researches have confirmed that the meaning of a word
that designates a concrete object is stored in two coordinate systems: (1) in a formal
logic-based hierarchical system of categorical meanings, and (2) in a visual image
“gallery of generalised images” associated with the referential meaning of the word.
Members of the “gallery of generalised images” are grouped according to the principle
of “family resemblance” around their prototypes (Rosch, 1975). The degree of typicality
determines how easy it is to operate with the given concept. For example, if we ask
subjects to evaluate the truth of the propositions “A crow is a bird” and “A chick is a
bird”, it will take less time to verify the first proposition than the second, which names a
non-typical category member (Rosch, Simpson, & Miller, 1976). As for the concepts
that are members of a hierarchical system of categorical meanings, they show another
effect, namely the effect of the distance between categories (Collins & Loftus, 1975;
Collins & Quillian, 1969). The experiments on lexical recognition and word naming
have shown that two types of meaning representation—perceptual and conceptual—are
activated at differing rates (Flores d’Arcais, Schreuder, & Glazenborg, 1985).
Modern neuroimaging studies also demonstrate different contributions of temporal
and temporal-parietal-occipital areas in word retrieval. Left hemisphere temporal areas
(BA 19, BA 27, and BA 20) contribute to matching the sequences of speech sounds
transiently stored in a temporary buffer (Wernicke’s area) to the phonological form of
words stored in lexical long-term memory. Areas that include posterior superior temporal/
inferior parietal cortex (BA 39) constitute “core semantic regions” that can be distin-
guished in the comparison of activation areas during semantic categorisation on word vs.
phoneme detection (Demonet, Thierry, & Cardebat, 2005).
Luria relates the damage to the temporal-parietal-occipital junction, and in particular
BA 39, to the syndrome of semantic aphasia. The breakdown of the hierarchical system of
categorical meanings (conceptual framework) leads to the disruption of the normally
automatic retrieval of words and as a result patients start to experience difficulty finding
words, take long time to search for the necessary word, or replace it with verbal
paraphasias. On the surface, disturbances of expressive speech experienced by patients
with semantic aphasia are similar to difficulties of patients with acoustic-mnestic aphasia,
but careful observation reveals differences both in the symptoms and in the mechanisms
of these difficulties. Thus, patients with semantic aphasia respond readily to cues, while
for patients with damage to temporal areas of the cortex, cues (sometimes even very
extensive ones) are not helpful.
Another confirmation of Luria’s understanding of naming deficits in different forms of
aphasia was found in the experimental study targeted at analysing the retention of
categorical meanings of words and referential meanings. Categorical classification (either
of words or of objects, retrieval of words with a given meaning (apple: fruit = dress:
???)) was the most difficult for the patients with semantic aphasia (Akhutina &
Malakhovskaia, 1985; Akhutina, 2003c; 2014). To analyse the ability to use referential
meanings, I and my student Natalia Komolova developed an experimental methodology
based on the idea that underlying such meaning is a generalised image-template, which is
used to segment the continuum of real phenomena. In this experiment, subjects were
asked to view schematic depictions of animals (cats, dogs, foxes, bears), whose features
changed smoothly along a single continuum, and divide them into groups. In addition to
this perceptual classification, they were asked to make verbal classification in which
words were to be placed in groups not on the basis of generic-specific categories, but
on the basis of whether they referred to one or another object (in particular, the words:
pussycat, kitty, to mew and to purr, had to be distinguished from puppy, cub, to bark, to
 Aphasiology 889

Table 3. Results of semantic tests given to subjects with different forms of aphasia (Akhutina &
Glozman, 1995).

Form of aphasia

Semantic Acoustic-mnestic Sensory Optico-mnestic

(n = 8) (n = 8) (n = 4) (n = 1)

Categorical significative meaning

Object subordinate 3.3 (0.7) 6.6 (1.2) 4.3 (3.1) 7.3
classification
Verbal subordinate 2.9 (1.2) 5.8 (1.1) 4.1 (2.9) 8.7
classification
Word selection 7.3 (0.3) 8.6 (0.6) - -
Referential meaning
Perceptual classification 7.95 (1.1) 4.85 (1.0) 6.8 (1.6) 2.5
Sorting words by their 9.2 (0.3) 6.35 (0.7) 8.5 (0.5) 9.8
referents
Mean severity of aphasia 256 (20.6) 253 (22) 147 (21) 280
Notes: The explanations are in the text. The worse results are indicated in bold.

growl or Brer, vixen, intoed). The difficulties in this verbal classification task and the task
of continuum segmentation, which were intercorrelated for these tasks but not correlated
with defects in performing tasks involving categorical meanings, were the most pro-
nounced in patients with acoustic-mnestic aphasia (Akhutina, 2003c, 2014; Akhutina &
Glozman, 1995). The results of our experimental study of referential and categorical
meanings are presented in Table 3.
A second component of the syndrome of semantic aphasia refers to difficulties in
understanding of logical-grammatical constructions. Patients with semantic aphasia can
easily grasp the meaning of simple sentences. However, they have difficulties compre-
hending multi-word constructions, which cannot be understood without first identifying
their grammatical relationship (Luria, 1970, p. 230). Examples of such constructions are
the following: “father’s brother”, “a circle is under the cross”, “less bright”, and so on. For
these constructions, Luria, after 1975, used the term “reversible constructions”, first
proposed by Slobin (1966). The semantic aphasic patient Lev Zasetsky, a protagonist of
Luria’s romantic essay “The Man With a Shattered World” (1987), wrote in his diary
about how he was trying to understand the utterance an elephant is bigger than a fly:

I realized that a fly is small and an elephant is big but to understand these words and answer
the question, whether a fly is smaller or bigger than an elephant, I for some reason could not.
The main problem was that I could not understand what does the word “smaller” (or
“bigger”) refer to—a fly or an elephant. (Luria, 1987)

In the same vein, this patient had difficulties understanding reversible active and
passive utterances. Comparative analysis of production, understanding, and verification
of such sentences in patients with efferent motor, acoustic-mnestic, and semantic aphasia,
as well as of understanding of such sentences by Russian-speaking children between 3
and 5 years of age is presented in my book (Akhutina, 1989/2012). Similar data on
difficulties in understanding reversible structures in patients with conduction aphasia (with
close localisation of the deficit) were obtained by Berndt and Caramazza (1981). A new
article about comprehension of reversible sentences by patients with semantic aphasia is
890 T. Akhutina

worth mentioning (Dragoy, Bergelson, Iskra, & Koshelev et al., 2015). The authors show
that in order to circumvent speech comprehension deficits, these patients use ontogenetic
sensory-motor stereotypes that reflect normal sequences of object manipulation.

Afferent motor aphasia

Afferent motor aphasia is caused by damage to the lower portions of the postcentral area
(see Figure 3, right). It is usually seen within a syndrome that also includes apraxia of
pose and oral apraxia. In severe cases, motor problems are so bad that patients cannot
produce a single articulate sound. When they try to repeat one or another sound, they
move their lips and tongue, and puff out their cheeks, but do not hit on the articulation
required. In mild cases, patients merely slip into similar articulation patterns. Writing
errors due to difficulties in differentiation of letters that correspond to the sounds close in
pronunciation are persistent. Usually, a patient’s actual speech, especially pronunciation of
certain well-mastered set phrases, suffers less than the arbitrary repetition of individual
sounds and clusters of consonants.
The primary deficit of afferent motor aphasia, which is the basis for this form of
aphasia and the whole syndrome of non-verbal and verbal deficiencies, is connected to the
afferent aspect of motor processes. The important role of feedback in motor control was
demonstrated by Russian physiologists Leon Orbeli, Petr Anokhin, and Nikolai Bernstein.
Their works, especially “The Construction of Movement” (Bernstein, 1947/1967), have
become a theoretical foundation for the distinction of the two types of motor aphasia: in
efferent motor aphasia, dynamic components of articulation are impaired, while afferent
motor aphasia is marked by impaired posture of the articulatory apparatus (Luria, 1970).
Well-known aphasiologists Shinn and Blumstein (1983) wrote about the former syn-
drome: “Broca’s aphasics seemed to be able to reach the articulatory configuration for
the appropriate place of articulation. However, the dynamic aspects of speech production
seemed to be impaired.”
Russian authors showed that in afferent motor aphasia, the substitutions of sounds are
connected with changes of manner and place of articulation, and mixture of hard and soft
consonants; contrary to efferent motor aphasia, in case of afferent aphasia, replacing
voiced consonants by voiceless ones is possible but not typical (Vinarskaya, 1971;
Sumchenko, 1974). Luria wrote on the syndrome of afferent motor aphasia: “The dis-
turbance of differentiations among similar articulatory positions is one of the most
characteristic symptoms of this form of aphasia” (Luria, 1970, p. 153) and noted that
“These disorders differ from those seen in premotor lesions in that the articulation
difficulty is unaccompanied by any sign that the dynamics of speech processes have
been disturbed” (Luria, 1970, p. 152). Though this type of aphasia is close to apraxias
seen in inferior frontal-parietal area damage, and therefore could be considered as a
positional apraxia of the speech organs, the deficit is not limited to the purely technical
level of pronunciation. The syndrome also includes pronounced writing and reading
disturbances. Explaining the syndrome of afferent motor aphasia, Luria wrote that “the
difficulty of the latter lies almost completely in mastering the schemata of articulatory
movements” (Luria, 1970, p. 154). The loss of generalised articulatory schemata affects
not only articulation but also writing and reading. The main writing problem is the
disturbance of sound awareness. Thus, when writing letters from dictation, the patient
repeats the sound, and only after having found a word that starts with this sound (“T, t,
t. . .. Tanya”) is she able to put down the letter. This method of writing has been used by
 Aphasiology 891

patients with afferent motor aphasia for many years, whereas patients with other types of
aphasia use it as a temporary help.
There is an opinion that afferent motor aphasia is closely comparable to conduction
aphasia (see, e.g., Goodglass & Kaplan, 1994, p. 86). Luria himself pointed out that the
main symptom of conduction aphasia—difficulty in repeating sounds and words in the
correct order—can be seen in different syndromes and it also appears in voluntary forms
of speech. Luria wrote:

In some cases it appears as a mild form of acoustic-gnostic disturbance, in others as a defect

of verbal articulation, and in still others as what Goldstein has described as a disturbance of
the “abstract attitude” necessary for the voluntary repetition of words spoken by others.
(Luria, 1970, p. 245)

His coworker Elena Kok has described three patients with conduction aphasia connected
with instability of the auditory images of words (Kok, 1965b). The neuropsychologists from
St. Petersburg explained the mechanism of conduction aphasia by disorders of operational
memory (Tonkonogii, Tsukerman, & Schklovskii, 1965). In “Traumatic aphasia”, Luria has
described a patient, Sukh, with parietal lobe syndrome who tended to reverse the order of
sounds or letters when repeating and writing words (pp. 429–430). Luria also mentioned
patients with such symptoms with lesions to the left temporal lobe (pp. 140, 292). Different
mechanisms that cause the symptoms of conduction aphasia were described by western
researchers (Dubois, Hécaen, Angelergues, Maufras Du Chatelier, & Marcie, 1964; Shallice
& Warrington, 1977; Tzortzis & Albert, 1974).
Figure 4 summarises the different components of speech and language abilities
disturbed in different forms of aphasia. The comparison of Lurian and Western aphasia
classifications is represented in Figure 5; one can see relations of aphasias distinguished in
both classifications (cp. Ardila, 2010).

Conclusions
We have completed the discussion of the Lurian classification of aphasias. The under-
standing of syndrome proposed by Luria makes it possible to differentiate the primary

Disorders of expressive speech Disorders of speech reception

Dynamic Syntactic Efferent Afferent Semantic Acoustic- Sensory
1 (Dynamic 2) mnestic
Utterance planning
Grammatical
structuring
Construction of a
syllabic schema of
the phrase
Kinesthetically
guided selection of
sound
Semantic-based
selection of word
Selection of word
form (lexeme)
Phonemic control
of speaker’s output

Figure 4. The disorders of language production components in different forms of aphasia

(Ryabova (Akhutina), 1967/2003).
892 T. Akhutina

Figure 5. Lurian and Western classifications of aphasia.

*Blumstein, Baker, and Goodglass (1977) Phonological Factors in Auditory Comprehension.
**Shallice and Warrington (1977) Auditory-verbal short-term memory and conduction aphasia.

and secondary defects and to qualify language disturbances drawing on the analysis of
non-verbal functions which are often easier to specify than speech/language deficits. In
the case of motor speech deficits, qualification of the type of aphasia based on speech
alone can be difficult. Analysis of praxis allows making an assumption about the type
of motor aphasia—afferent, efferent, or combined—observed in a given patient. For
example, a detailed description of the state of praxis is given when discussing syntactic
aphasia syndrome (Akhutina, 1989/2012, pp. 125–129). The necessity of the analysis
of non-verbal functions is discussed in detail by Maria Khrakovsky. She shows the
insufficiency of language tests when choosing methods of rehabilitation
(Khrakovskaya, 2009, 2012).
The inverse dynamics of the speech deficits allows for the confirmation of the
diagnosis. (For dynamics of language test performance in patients with different severity
 Aphasiology 893

of speech/language disorders, see Tsvetkova, Akhutina, Polonskaya, & Pylaeva, 1979;

Tsvetkova, Akhutina, & Pylaeva, 1981, pp. 41–53; Akhutina, 2014, pp. 69–93. An
example of a longitudinal study of patients with premotor syndrome is given in
Akhutina, 1989/2012.)
It is also helpful to determine what shared external techniques are most effective in
rehabilitation of each aphasic patient (on the case of dynamic aphasia, see Luria, 1970, pp.
452–456, Luria & Tsvetkova, 1968; Akhutina, 1975/2002, pp. 18–21; on the case of
acoustic-mnestic aphasia, see; Luria, 1973, pp. 158–160; Tsvetkova, 1975; Kalita, 1975;
Khrakovskaya & Evstyunina, 2014; on the case of afferent motor aphasia, see Geras’kina,
2001). Unfortunately, within the limits of the paper, one cannot dwell on rehabilitation
methods based on Vygotskian-Lurian ideas. Nevertheless, a reader may find the review of
approaches and some examples of methods in our publications (Akhutina et al., in press;
Akhutina & Pylaeva, 2012, pp. 43–47; Akhutina & Shereshevsky, 2014, pp. 365–369).
Thus Lurian neuropsychology offers a wide array of tools for psychological qualifica-
tion of various cognitive deficits:

(1) Neuropsychological system analysis of verbal and other HMFs with the differ-
entiation between primary and secondary defects;
(2) Monitoring the dynamic changes of the syndrome; and
(3) Determination of the external compensatory techniques.

This body of Lurian neuropsychology is much richer than the simple statement of the
“double dissociation of functions”, and its use makes analysis of aphasia syndromes more
precise.

Acknowledgements
I want to express my sincere gratitude to Zara Melikian, Maria Falikman, Kelly Callahan and Ekaterina
Pechenkova, who helped in translating and preparing this publication. I am also grateful to my American
colleagues Nina Dronkers, William Barr, Cris Morrison and Gary Shereshevsky for encouraging me in
writing the article. I has a pleasant task of expressing my sincere thanks to Elena Radkovckaya for her
permission to publish the figures from A.R. Luria’s book “Traumatic aphasia” (1947).

Disclosure statement
No potential conflict of interest was reported by the author.

ORCID
Tatiana Akhutina http://orcid.org/0000-0002-8503-2495

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